Coordinating Your Care
Sutter Regional Medical Foundation

Sutter Regional Medical Foundation Utilization Management Program

Sutter Regional Medical Foundation utilization management (UM) program is designed to ensure that managed care members receive timely, medically necessary, and cost-effective health care services. Services that we provide to our patients as part of the program include:

• Prior authorization/concurrent review
• Discharge planning
• Care management
• Retrospective review

Our UM staff, including RNs, LVNs and trained representatives, work closely with our medical staff to help coordinate care by outside specialists. Our goal is to meet the needs of our patients as well as the program.

The managed care plans include Aetna, Blue Shield, California Care, Health Net, Health Net Seniority Plus, Pacificare Secure Horizons (SDMG), Partnership Health Plan, United Healthcare / Pacificare and WHA.

Utilization Management Policies and Procedures

• Guidelines – Sutter Regional Medical Foundation uses approved guidelines from the health plans medical management policies and Milliman & Robertson criteria (approved by the health plans) to review referral requests submitted by contracted providers and primary care physicians. These guidelines are reviewed and updated by these organizations periodically to remain current with new treatment and trends. The criteria provide a guideline only to approve, modify or deny care for persons with similar conditions. Specific care and treatment may vary depending on individual need and benefits covered under the individual's plan. The criteria are available on request for a specific treatment.
• Decision Making – Sutter Regional Medical Foundation ensures that decisions are made only on appropriateness of care, service and existence of coverage. SRMF managed care staff or providers do not receive any compensation, direct or indirect or financial incentives based on review decisions.
• Sutter Regional Medical Foundation encourages appropriate utilization and discourages inappropriate under-utilization by providers and staff.

Any questions regarding this notice may be directed to Utilization Management at 707-434-2086 or 866-232-5313.

If you have concerns regarding the Utilization Management process, have questions regarding services or communications you may have received, or need to contact a Referral Specialist, please call 707-434-2086.